Associations between Th1-related cytokines and complicated pediatric appendicitis

The pathogenesis of appendicitis is not understood fully, and the diagnosis can be challenging. Previous research has suggested an association between a T helper (Th) 1-dependent immune response and complicated appendicitis. This prospective cohort study aimed to evaluate the association between serum concentrations of the Th1-associated cytokines interleukin (IL)-1α, IL-1β, IL-2, IL-6, IL-10, IL-17A and tumor necrosis factor beta (TNF-β) and the risk of complicated appendicitis in children. Appendicitis severity was determined through histopathological examination. A total of 137 children < 15 years with appendicitis were included with a median age of 10 years (IQR 8-12); 86 (63%) were boys, and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of serum IL-6 and IL-10, and lower of TNF-β. After adjustment for age, symptom duration, and presence of appendicolith in a multivariable logistic regression, a higher concentration of IL-6 remained associated with an increased risk of complicated appendicitis (aOR 1.001 [95% CI 1.000-1.002], p = 0.02). Serum concentrations of IL-1α, IL-1β, IL-2, IL-10, IL-17A and TNF-β were not significantly associated with the risk of complicated appendicitis. In conclusion, our results suggests that the systemic inflammatory response in complicated appendicitis is complex and not solely Th1-dependent.

Supranormal differential renal function on MAG3 scan in children with ureteropelvic junction obstruction - Prevalence and pyeloplasty during follow-up

BACKGROUND

Children with suspected ureteropelvic junction obstruction (UPJO) may present with a paradoxical ipsilateral supranormal differential renal function (snDRF) on 99mTechnetium mercaptoacetyltriglycine scintigraphy (MAG3 scan).

OBJECTIVE

The aim was to investigate the prevalence of snDRF, the risk of pyeloplasty among children with UPJO and snDRF, and to explore the experience of snDRF among international pediatric urologists.

METHODS

A retrospective cohort study of children with suspected unilateral UPJO who underwent MAG3 scan at four hospitals in Sweden between 2005 and 2020. SnDRF was defined as DRF ≥55%. Normal DRF was defined as DRF 45-54%. Primary outcome was risk of pyeloplasty. Indications for pyeloplasty were loss of >10%-points of differential renal function (DRF), ipsilateral DRF <40%, or symptomatic UPJO. Logistic and cox regressions were performed in univariate and multivariable analyses, adjusting for age, gender, year, laterality, antenatal hydronephrosis, anterior-posterior diameter (APD), and kidney size. An international questionnaire regarding the management of snDRF was developed and distributed to pediatric urologists.

RESULTS

The prevalence of snDRF was 19%. SnDRF was more common in boys, children with antenatal hydronephrosis, children undergoing their first MAG3 scan at a younger age, and in the left kidney. After further exclusion of 70 children with DRF <45%, a total of 264 were included for longitudinal follow-up of median 6.6 (IQR 2.5-11.5) years. SnDRF was not associated with increased risk of pyeloplasty (adjusted OR 0.98 (95% CI 0.41-2.33), p = 0.96, and adjusted HR 1.00 (95% CI 0.53-1.91), p = 0.99) or time to pyeloplasty (1.1 years vs. 1.6 years, p = 0.40). Among the 79 surveyed pediatric urologists, a majority would not change clinical UPJO-management based on the presence or absence of ipsilateral snDRF.

DISCUSSION

There are only a few studies considering the need of pyeloplasty based on the presence of snDRF and this is the first survey among pediatric urologists on its management. With more included patients than previous studies, this study showed a snDRF prevalence of 19%, congruent with the findings of others. The underlying cause of snDRF is debated, but it cannot solely be explained as an artifact of hydronephrotic kidneys. Further studies on the clinical implications of snDRF are warranted, since DRF influences the decision to operate.

CONCLUSION

A fifth of all children with suspected UPJO presented with ipsilateral snDRF on initial MAG3 scan, and snDRF was not associated with a greater risk of pyeloplasty. Supported by a large group of international pediatric urology colleagues, this study concludes that the same clinical follow-up and management apply, regardless of presence of snDRF.

Surgical management of necrotizing enterocolitis in Sweden: a national cohort study

AIM

Necrotizing enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management, and mortality for surgically treated neonates with NEC.

METHODS

Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded.

RESULTS

In total, 109 neonates were included. Median gestational age was 25 weeks (22-38) and median birth weight was 771 grams (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25%, and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multi-focal NEC in 35 (36%), and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip and drop technique was applied in 24/87 (28%) Mortality rate was 37%.

CONCLUSION

Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

South Africa and the Surgical Diaspora-A Hub for Surgical Migration and Training

BACKGROUND

The shortage of trained surgeons, anesthesiologists, and obstetricians is a major contributor to the unmet need for surgical care in low- and middle-income countries, and the shortage is aggravated by migration to higher-income countries.

METHODS

We performed a cross-sectional observational study, combining individual-level data of 43,621 physicians from the Health Professions Council of South Africa with data from the registers of 14 high-income countries, and international statistics on surgical workforce, in order to quantify migration to and from South Africa in both absolute and relative terms.

RESULTS

Of 6670 surgeons, anesthesiologists, and obstetricians in South Africa, a total of 713 (11%) were foreign medical graduates, and 396 (6%) were from a low- or middle-income country. South Africa was an important destination primarily for physicians originating from low-income countries; 2% of all surgeons, anesthesiologists, and obstetricians from low- and middle-income countries were registered in South Africa, and 6% in the other 14 recipient countries. A total of 1295 (16%) South African surgeons, anesthesiologists, and obstetricians worked in any of the 14 studied high-income countries.

CONCLUSION

South Africa is an important regional hub for surgical migration and training. A notable proportion of surgical specialists in South Africa were medical graduates from other low- or middle-income countries, whereas migration out of South Africa to high-income countries was even larger.

Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings

BACKGROUND

A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner.

METHODS

We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000.

RESULTS

The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics.

CONCLUSIONS

While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

Acute burn care and outcomes at the Hospital Nacional Guido Valadares (HNGV), Timor-Leste: A 7-year retrospective study

The purpose of this study was to describe the epidemiology of patients presenting with acute burns and undergoing admission at Hospital Nacional Guido Valadares (HNGV) in Dili, Timor-Leste in the period 2013 to 2019. HNGV is the only tertiary referral hospital in Timor-Leste. This was a retrospective study involving all acute burn patients admitted to the surgical wards of HNGV from 2013 to 2019. The data was collected from patient charts and hospital medical archives. Data were reviewed and analyzed statistically in terms of age, gender, residence, cause, total body surface area (TBSA), burns depth, length of stay (LOS), and mortality. The outcomes were analyzed using logistic regression. Over the 7-year period, there were 288 acute burn patients admitted to the surgical wards of HNGV. Most patients were children (55%), male (65%) and from the capital city of Dili or surrounding areas (59%). The most common cause of burns in children was scalds and the most common cause among adults was flames. Of the admitted patients 59% had burns affecting >10% of the TBSA and 41% had full thickness burns. The median LOS was 17 days (1-143) and the average mortality for admitted burn patients in HNGV was 5.6% (annual mortality 0-17%). The odds ratio for extended LOS was 1.9 (95% confidence interval 1.1-3.2) in female compared with male patients. The odds ratio for mortality was 14.6 (95% confidence interval 2.7-80.6) in the older adults when compared with younger adults. Higher TBSA, full thickness burns, and flame burns were also significantly associated with longer LOS and higher mortality. Children and male patients were disproportionately overrepresented among patients admitted to HNGV, while female patients had longer LOS and older adults had more severe injury and a higher risk of mortality. Establishment of a national program for the prevention of burns is essential.

Differential Activation of Immune Effector Processes in Mature Compared to Immature Sacrococcygeal Teratomas

Objective: This study aims to characterize the molecular signatures of sacrococcygeal teratomas (SCTs). Methods: Three SCTs were analyzed with whole genome genotyping. RNA sequencing of 10 SCTs dominated by mature, immature and neuroglial elements was analyzed. Expression in SCT-samples with different elements were compared to each other and to a reference group of malignant pediatric tumors. Macrophages, T- and B-lymphocytes were detected by immunohistochemistry. Results: No chromosomal imbalances were detected. SCTs showed overexpression of genes involved in neurosignaling, DNA-binding molecules and pathways of early germ cells. Genes associated with immune effector processes were overexpressed in mature compared to immature SCTs, and immune cell infiltration was found predominantly around mature epithelial elements. Conclusion: The broad repertoire of histological elements in SCTs reflects differences in transcriptional regulation rather than differences in gene copy numbers. A paucity of immune response in immature SCTs may be a factor contributing to their uninhibited growth.

Systematic review of low-income and middle-income country perceptions of visiting surgical teams from high-income countries

BACKGROUND

The shortage of surgeons, anaesthesiologists and obstetricians in low-income and middle-income countries (LMICs) is occasionally bridged by foreign surgical teams from high-income countries on short-term visits. To advise on ethical guidelines for such activities, the aim of this study was to present LMIC stakeholders' perceptions of visiting surgical teams from high-income countries.

METHOD

We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in November 2021, using standardised search terms in PubMed/Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO) and Global Index Medicus, and complementary hand searches in African Journals Online and Google Scholar. Included studies were analysed thematically using a meta-ethnographic approach.

RESULTS

Out of 3867 identified studies, 30 articles from 15 countries were included for analysis. Advantages of visiting surgical teams included alleviating clinical care needs, skills improvement, system-level strengthening, academic and career benefits and broader collaboration opportunities. Disadvantages of visiting surgical teams involved poor quality of care and lack of follow-up, insufficient knowledge transfers, dilemmas of ethics and equity, competition, administrative and financial issues and language barriers.

CONCLUSION

Surgical short-term visits from high-income countries are insufficiently described from the perspective of stakeholders in LMICs, yet such perspectives are essential for quality of care, ethics and equity, skills and knowledge transfer and sustainable health system strengthening. More in-depth studies, particularly of LMIC perceptions, are required to inform further development of ethical guidelines for global surgery and support ethical and sustainable strengthening of LMIC surgical systems.

An Evaluation of Serum IgE and Th2-Associated Interleukins in Children With Uncomplicated and Complicated Appendicitis

BACKGROUND

The pathogenesis of appendicitis is not understood completely and establishing a correct diagnosis can be clinically challenging. Previous investigations have shown an association between a T helper cell (Th)2-mediated inflammatory response, for example immunoglobulin E (IgE)-mediated allergy, and a decreased risk of complicated appendicitis. The present study aimed to evaluate differences in serum concentrations of IgE and Th2-associated interleukins (IL) in children with uncomplicated and complicated appendicitis.

METHOD

A prospective study including children <15 years with appendicitis. Blood samples were collected preoperatively at the time of clinical assessment at the Pediatric Emergency Department and analyzed for concentrations of serum total IgE and IL-4, IL-9, and IL-13. Associations with complicated appendicitis were evaluated through logistic regression adjusting for age, appendicolith, and symptom duration.

RESULTS

138 children with confirmed appendicitis were included. The median age was 10 (IQR 8-12) years, 87 (63%) were boys and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of IL-9 and IL-13 compared to children with uncomplicated appendicitis. In the univariate logistic regression, high concentrations of IL-13 were associated with an increased risk of complicated appendicitis [OR 1.02 (95% CI 1.01-1.04) p = 0.005], which remained in the multivariate analysis [aOR 1.02 (95% CI 1.01-1.04), p = 0.01]. Serum concentrations of IgE, IL-4, and IL-9 did not significantly affect the risk of complicated appendicitis.

CONCLUSION

High levels of IL-13 seem to be associated with an increased risk of complicated appendicitis. This is incongruent with the hypothesis of an Th1/Th17-driven inflammation in this type of appendicitis.

The Development and Inclusion of Questions on Surgery in the 2018 Zambia Demographic and Health Survey

Data from household surveys serve as the backbone to sustainable development planning. For the first time, questions on surgery have been included in a nationwide Demographic and Health Survey, showing that it is feasible to integrate these questions into a large-scale survey.

Background:

While primary data on the unmet need for surgery in low- and middle-income countries is lacking, household surveys could provide an entry point to collect such data. We describe the first development and inclusion of questions on surgery in a nationally representative Demographic and Health Survey (DHS) in Zambia.

Method:

Questions regarding surgical conditions were developed through an iterative consultative process and integrated into the rollout of the DHS survey in Zambia in 2018 and administered to a nationwide sample survey of eligible women aged 15–49 years and men aged 15–59 years.

Results:

In total, 7 questions covering 4 themes of service delivery, diagnosed burden of surgical disease, access to care, and quality of care were added. The questions were administered across 12,831 households (13,683 women aged 15–49 years and 12,132 men aged 15–59 years). Results showed that approximately 5% of women and 2% of men had undergone an operation in the past 5 years. Among women, cesarean delivery was the most common surgery; circumcision was the most common procedure among men. In the past 5 years, an estimated 0.61% of the population had been told by a health care worker that they might need surgery, and of this group, 35% had undergone the relevant procedure.

Conclusion:

For the first time, questions on surgery have been included in a nationwide DHS. We have shown that it is feasible to integrate these questions into a large-scale survey to provide insight into surgical needs at a national level. Based on the DHS design and implementation mechanisms, a country interested in including a set of questions like the one included in Zambia, could replicate this data collection in other settings, which provides an opportunity for systematic collection of comparable surgical data, a vital role in surgical health care system strengthening.

Nationwide paediatric cohort study of a protective association between allergy and complicated appendicitis

BACKGROUND

In a nationwide cohort the potentially protective association between allergy and complicated appendicitis was analysed, and the influence of seasonal antigens, antihistamine treatment, and timing of allergy onset assessed.

METHODS

Some 1 112 571 children born between 2000 and 2010 were followed from birth until the end of 2014. A cross-sectional analysis of appendicitis cases, with comparison of allergic versus non-allergic children for absolute risk and odds of complicated appendicitis was first undertaken. This was followed by a longitudinal analysis of children with allergy and matched controls who had never had an allergy, for incidence rate and hazard of subsequent complicated or simple appendicitis.

RESULTS

Of all children, 20.4 per cent developed allergy and 0.6 per cent had appendicitis during follow-up. Among children with appendicitis, complicated appendicitis was more common among non-allergic children (18.9 per cent, 948 of 5016) than allergic children (12.8 per cent, 173 of 1351) (P < 0.001), and allergic children had a lower adjusted odds of complicated appendicitis (adjusted odds ratio (OR) 0.80, 95 per cent c.i. 0.67 to 0.96; P = 0.021). The risk of complicated appendicitis among children with manifest allergy was reduced by one-third in the longitudinal analysis (incidence rate 0.13 versus 0.20 per 1000 person-years; hazard ratio (HR) 0.68, 95 per cent c.i. 0.58 to 0.81; P < 0.001), whereas the risk of simple appendicitis remained unchanged (incidence rate 0.91 versus 0.91; HR 1.00, 0.94 to 1.07; P = 0.932). Seasonal antigen exposure was a protective factor (adjusted OR 0.82, 0.71 to 0.94; P = 0.004) and ongoing antihistamine medication a risk factor (adjusted OR 2.28, 1.21 to 4.28; P = 0.012).

CONCLUSION

Children with allergy have a lower risk of complicated appendicitis, but the same overall risk of simple appendicitis. Seasonal antigen exposure reduced, and antihistamine treatment increased, the risk of complicated disease.

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative

BACKGROUND

Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI.

METHODS

Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed.

RESULTS

For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure.

CONCLUSION

Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

BACKGROUND

Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.

METHODS AND FINDINGS

The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees.

CONCLUSIONS

To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Associations of hair cortisol concentrations with paediatric appendicitis

The pathogenesis of paediatric appendicitis is still an enigma. In recent years, it has become more evident that our inherent immunological responses affect the trajectory of the disease course. Long-term stress has an impact on our immune system; however, it is practically and ethically challenging to prospectively track blood measurements of cortisol-levels in asymptomatic children should an acute appendicitis episode develop. The aim of this case–control study was therefore to evaluate the effect of increased stress measured as historical imprints in hair (hair cortisol concentrations [HCC]), on the risk of developing appendicitis and complicated appendicitis. 51 children (aged < 15 years) with appendicitis (34 with complicated appendicitis), were compared to 86 healthy controls. HCC reflecting the activity of the HPA-axis 0–3 and 4–6 months prior to sampling was evaluated and compared between groups as well as between the two measurements of each study subject. In the univariate analysis with both cases and controls, an increase in HCC between the measurement timepoints was associated with a substantial increase in risk of appendicitis (OR 7.52 [95% CI 2.49–22.67], p = 0.001). This increased risk remained in the multivariate analysis after adjustment for age, sex and season (aOR OR 10.76 [95%CI 2.50–46.28], p  = 0.001). When comparing the cases of uncomplicated and complicated appendicitis through a multivariate analysis, adjusted for age and sex, the children with an increased HCC prior to appendicitis had a substantial and statistically significant increase in risk of complicated appendicitis (aOR 7.86 [95% CI 1.20–51.63], p = 0.03). Biological stress, measured as an increase in HCC, seems to be associated with an increased risk of paediatric appendicitis and a more complicated disease course.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Association of transport time with adverse outcome in paediatric trauma

Background

It is unclear how the length of prehospital transport time affects outcome in paediatric trauma. This study evaluated the association of transport time from alarm to arrival at hospital with adverse outcome in paediatric trauma patients in Sweden.

Methods

This was a retrospective study based on prospectively collected data from the Swedish trauma registry between 2012 and 2019 of children less than 18 years with major trauma (New Injury Severity Score (NISS) greater than 15). The primary outcome was 30-day mortality, and secondary outcomes were emergency interventions (e.g., chest tube or laparotomy) and low functional outcome (Glasgow Outcome Scale 2–3). Primary exposure was transport time from alarm to arrival at hospital. Co-variables in multivariable regressions were gender, age, ASA score before injury, injury intention, dominant injury type, NISS, Glasgow Coma Scale score, prehospital competence and hospital level.

Results

Among 597 patients, 30-day mortality was 9.8 per cent, emergency interventions were performed in 34.7 per cent and low functional outcome was registered in 15.9 per cent. Median transport time was 51 (i.q.r. 37–68) minutes. After adjustment for patient, injury and hospital characteristics, no association between longer transport time and 30-day mortality, frequency of emergency interventions or lower functional outcome could be found. Treatment at a university hospital was associated with a lower risk for 30-day mortality (odds ratio 0.23 (95 per cent c.i. 0.08 to 0.68), P = 0.008).

Conclusion

Longer transport time after major paediatric trauma was not associated with adverse outcome. Hence, it seems that longer transport distances should not be an obstacle against centralization of paediatric trauma care. Further studies should focus on the role of prehospital competence and other transport-associated parameters and their association with adverse outcome.

A Nationwide Cohort Study of Outcome after Pediatric Appendicitis

INTRODUCTION

 Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome.

MATERIALS AND METHODS

 A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 (n = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time.

RESULTS

 Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18-3.18], p < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08-5.53], p < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61-5.78], p < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62-0.89], p = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11-0.63], p = 0.002).

CONCLUSION

 Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for.

Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe

BACKGROUND

Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay.

METHODS

This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed.

RESULTS

Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin.

CONCLUSION

A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children.

LEVELS OF EVIDENCE

Level II treatment study.

The Effect of Botulinum Toxin Type A Injections on Stricture Formation, Leakage Rates, Esophageal Elongation, and Anastomotic Healing Following Primary Anastomosis in a Long- and Short-Gap Esophageal Atresia Model - A Protocol for a Randomized, Controlled, Blinded Trial in Pigs

BACKGROUND

Esophageal atresia (EA) is a congenital malformation affecting 1:3000-4500 newborns. Approximately 15% have a long-gap EA (LGEA), in which case a primary anastomosis is often impossible to achieve. To create continuity of the esophagus patients instead have to undergo lengthening procedures or organ interpositions; methods associated with high morbidity and poor functional outcomes. Esophageal injections of Botulinum Toxin Type A (BTX-A) could enable primary anastomosis and mitigate stricture formation through decreased tissue tension.

METHODS AND ANALYSIS

In this randomized controlled blinded animal trial, 24 pigs are divided into a long- or short-gap EA group (LGEA and SGEA, respectively) and randomized to receive BTX-A or isotonic saline injections. In the LGEA group, injections are given endoscopically in the esophageal musculature. After seven days, a 3 cm esophageal resection and primary anastomosis is performed. In the SGEA group, a 1 cm esophageal resection and primary anastomosis is performed, followed by intraoperative injections of BTX-A or isotonic saline. After 14 days, stricture formation, presence of leakage, and esophageal compliance is assessed using endoscopic and manometric techniques, and in vivo and ex vivo contrast radiography. Tissue elongation is evaluated in a stretch-tension test, and the esophagus is assessed histologically to evaluate anastomotic healing.

ETHICS AND DISSEMINATION

The study complies with the ARRIVE guidelines for animal studies and has been approved by the Danish Animal Experimentation Council. Results will be published in peer-reviewed journals and presented at national and international conferences.

HIGHLIGHTS

The optimal management of long-gap esophageal atresia remains controversialPrimary anastomosis could improve functional outcomes and reduce complicationsBotulinum Toxin Type A decreases tissue tension and could facilitate anastomosisReduced tension could further abate the risk for anastomotic stricture and leakageWe present a model to evaluate the method in long- and short-gap esophageal atresia.

Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone

INTRODUCTION

Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance.

METHODS

Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed.

RESULTS

The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001).

CONCLUSION

The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.

Hyponatraemia despite isotonic maintenance fluid therapy: a time series intervention study

OBJECTIVE

To examine the prevalence of dysnatraemias among children admitted for paediatric surgery before and after a change from hypotonic to isotonic intravenous maintenance fluid therapy.

DESIGN

Retrospective consecutive time series intervention study.

SETTING

Paediatric surgery ward at the Children's Hospital in Lund, during a 7-year period, 2010-2017.

PATIENTS

All children with a blood sodium concentration measurement during the study period were included. Hypotonic maintenance fluid (40 mmol/L NaCl and 20 mmol/L KCl) was used during the first 3 years of the study (646 patients), and isotonic solution (140 mmol/L NaCl and 20 mmol/L KCl) was used during the following period (807 patients).

MAIN OUTCOME MEASURES

Primary outcomes were sodium concentration and occurrence of hyponatraemia (<135 mmol/L) or hypernatraemia (>145 mmol/L).

RESULTS

Overall, the change from hypotonic to isotonic intravenous maintenance fluid therapy was associated with a decreased prevalence of hyponatraemia from 29% to 22% (adjusted OR 0.65 (0.51-0.82)) without a significantly increased odds for hypernatraemia (from 3.4% to 4.3%, adjusted OR 1.2 (0.71-2.1)). Hyponatraemia <130 mmol/L decreased from 6.2% to 2.6%, and hyponatraemia <125 mmol/L decreased from 2.0% to 0.5%.

CONCLUSIONS

Routine use of intravenous isotonic maintenance fluids was associated with lower prevalence of hyponatraemia, although hyponatraemia still occurred in over 20% of patients. We propose that the composition and the volume of administered fluid need to be addressed.

How boys and testicles wander to surgery: a nationwide cohort study of surgical delay in Sweden

BACKGROUND

Early orchidopexy is recommended for cryptorchidism and the surgery is increasingly centralised. The objectives were to determine the incidence, risk factors and if distance to treating hospital impacted on timely treatment of cryptorchidism.

METHODS

In this observational study, all boys born in Sweden from 2001 to 2014 were followed in national registers to determine the incidence of cryptorchidism by levels of birth-related risk factors and social determinants. Travel time to hospital was used as the primary exposure in multivariable survival analysis, with age at surgery as main outcome.

RESULTS

Of 748 678 boys at risk for cryptorchidism, 7351 were treated and evaluated for timing of surgery (cumulative childhood incidence 1.4%, 95% CI 1.3% to 1.5%). The incidence was clearly associated with prematurity and overdue pregnancy (HR for <32 weeks 2.77 (95% CI 2.39 to 3.21); 32-36 weeks HR 1.36 (95% CI 1.24 to 1.49); >41 weeks HR 1.19 (95% CI 1.10 to 1.29)), low birth weight (<1000 g HR 3.94 (95% CI 3.15 to 4.92); 1000-1499 g HR 3.70 (95% CI 3.07 to 4.46); 1500-2500 g HR 1.69 (95% CI 1.52 to 1.88)) and intrauterine growth restriction (small for gestational age HR 2.38 (95% CI 2.14 to 2.65); large for gestational age HR 1.26 (95% CI 1.13 to 1.42)), but not with smoking or maternal age. Each 30 min increase in travel time was associated with a reduced probability of timely treatment (HR for being treated by age 3 adjusted for risk factors and socioeconomic determinants: 0.91 (95% CI 0.88 to 0.95)). Lower income and financial support were also associated with treatment delays (adjusted HR for lowest income quintile 0.82 (95% CI 0.72 to 0.93) and for families with financial support 0.85 (95% CI 0.73 to 0.97)).

CONCLUSIONS

Travel distance to treating hospital was associated with delayed treatment. 'Not all those who wander are lost', but these findings suggest a trade-off between centralisation benefits and barriers of geography also in elective paediatric surgery.

Measuring the migration of surgical specialists

BACKGROUND

The lack of access to essential surgical care in low-income countries is aggravated by emigration of locally-trained surgical specialists to more affluent regions. Yet, the global diaspora of surgeons, obstetricians, and anesthesiologists from low-income and middle-income countries has never been fully described and compared with those who have remained in their country of origin. It is also unclear whether the surgical workforce is more affected by international migration than other medical specialists. In this study, we aimed to quantify the proportion of surgical specialists originating from low-income and middle-income countries that currently work in high-income countries.

METHODS

We retrieved surgical workforce data from 48 high-income countries and 102 low-income and middle-income countries using the database of the World Health Organization Global Surgical Workforce. We then compared this domestic workforce with more granular data on the country of initial medical qualification of all surgeons, anesthesiologists, and obstetricians made available for 14 selected high-income countries to calculate the proportion of surgical specialists working abroad.

RESULTS

We identified 1,118,804 specialist surgeons, anesthesiologists, or obstetricians from 102 low-income and middle-income countries, of whom 33,021 (3.0%) worked in the 14 included high-income countries. The proportion of surgical specialists abroad was greatest for the African and South East Asian regions (12.8% and 12.1%). The proportion of specialists abroad was not greater for surgeons, anesthesiologists, or obstetricians than for physicians and other medical specialists (P = .465). Overall, the countries with the lowest remaining density of surgical specialists were also the countries from which the largest proportion of graduates were now working in high-income countries (P = .011).

CONCLUSION

A substantial proportion of all surgeons, anesthesiologists, and obstetricians from low-income and middle-income countries currently work in high-income countries. In addition to decreasing migration from areas of surgical need, innovative strategies to retain and strengthen the surgical workforce could involve engaging this large international pool of surgical specialists and instructors.

Perinatal outcomes of cesarean deliveries in Sierra Leone: A prospective multicenter observational study

OBJECTIVE

To analyze the indications for cesarean deliveries and factors associated with adverse perinatal outcomes in Sierra Leone.

METHODS

Between October 2016 and May 2017, patients undergoing cesarean delivery performed by medical doctors and associate clinicians in nine hospitals were included in a prospective observational study. Data were collected perioperatively, at discharge, and during home visits after 30 days.

RESULTS

In total, 1274 cesarean deliveries were included of which 1099 (86.3%) were performed as emergency surgery. Of the 1376 babies, 261 (19.0%) were perinatal deaths (53 antepartum stillbirths, 155 intrapartum stillbirths, and 53 early neonatal deaths). Indications with the highest perinatal mortality were uterine rupture (45 of 55 [81.8%]), abruptio placentae (61 of 85 [71.8%]), and antepartum hemorrhage (8 of 15 [53.3%]). In the group with cesarean deliveries performed for obstructed and prolonged labor, a partograph was filled out for 212 of 425 (49.9%). However, when completed, babies had 1.81-fold reduced odds for perinatal death (95% confidence interval 1.03-3.18, P-value 0.041).

CONCLUSION

Cesarean deliveries in Sierra Leone are associated with an exceptionally high perinatal mortality rate of 190 per 1000 births. Late presentation in the facilities and lack of adequate fetal monitoring may be contributing factors.

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

Background

The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery.

Methods

This was a scoping review of all available literature pertaining to COVID-19 and surgery, using electronic databases, society websites, webinars and preprint repositories.

Results

Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross-cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning.

Conclusion

Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase.

Health-related quality of life and scar satisfaction in a cohort of children operated on for sacrococcygeal teratoma

Aim

The aims of this study were to evaluate health-related quality of life (HRQoL) in children with sacrococcygeal teratoma and to explore the effect of the scar on physical, emotional and behavioral aspects.

Methods

A cohort of children operated on for sacrococcygeal teratoma between 2000 and 2013 at Lund University Hospital, Sweden, and their parents were interviewed. HRQoL was evaluated with PedsQL, and scar satisfaction was estimated through Patient Observer Scar Assessment Score (POSA).

Results

All eligible children (n = 17) were included (100% response rate). Median age was 7.3 years (range 3.5–16.0). Mean total PedsQL score was 92.3 (range 72.0 to 99.0). Patients with comorbidity scored lower (87.5) than those without (95.0) (p < 0.05). Pain during sitting down was reported by two (20%) patients, and itching was reported by another two patients (20%) aged > 8 years. No children reported that they avoided situations due to the scar, and most (80% of children and 90% of parents) reported absent or only mild negative emotions when considering the scar.

Conclusion

Children with sacrococcygeal teratoma had a good overall HRQoL, but comorbidity reduced the outcome. A few children reported scar-related impact on physical, behavioral and emotional aspects.

Sustainable care for children with cancer: a Lancet Oncology Commission

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Where is the 'global' in the European Union's Health Research and Innovation Agenda?

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021-2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries.

The rate and perioperative mortality of caesarean section in Sierra Leone

Introduction

Sierra Leone has the world’s highest maternal mortality, partly due to low access to caesarean section. Limited data are available to guide improvement. In this study, we aimed to analyse the rate and mortality of caesarean sections in the country.

Methods

We conducted a retrospective study of all caesarean sections and all reported in-facility maternal deaths in Sierra Leone in 2016. All facilities performing caesarean sections were visited. Data on in-facility maternal deaths were retrieved from the Maternal Death Surveillance and Response database. Caesarean section mortality was defined as in-facility perioperative mortality.

Results

In 2016, there were 7357 caesarean sections in Sierra Leone. This yields a population rate of 2.9% of all live births, a 35% increase from 2012, with district rates ranging from 0.4% to 5.2%. The most common indications for surgery were obstructed labour (42%), hypertensive disorders (25%) and haemorrhage (22%). Ninety-nine deaths occurred during or after caesarean section, and the in-facility perioperative caesarean section mortality rate was 1.5% (median 0.7%, IQR 0–2.2). Haemorrhage was the leading cause of death (73%), and of those who died during or after surgery, 80% had general anaesthesia, 75% received blood transfusion and 22% had a uterine rupture diagnosed.

Conclusions

The caesarean section rate has increased rapidly in Sierra Leone, but the distribution remains uneven. Caesarean section mortality is high, but there is wide variation. More access to caesarean sections for maternal and neonatal complications is needed in underserved areas, and expansion should be coupled with efforts to limit late presentation, to offer assisted vaginal delivery when indicated and to ensure optimal perioperative care.

Nationwide study of appendicitis in children

Background

Paediatric surgical care is increasingly being centralized away from low‐volume centres, and prehospital delay is considered a risk factor for more complicated appendicitis. The aim of this study was to determine the incidence of paediatric appendicitis in Sweden, and to assess whether distance to the hospital was a risk factor for complicated disease.

Methods

A nationwide cohort study of all paediatric appendicitis cases in Sweden, 2001–2014, was undertaken, including incidence of disease in different population strata, with trends over time. The risk of complicated disease was determined by regression methods, with travel time as the primary exposure and individual‐level socioeconomic determinants as independent variables.

Results

Some 38 939 children with appendicitis were identified. Of these, 16·8 per cent had complicated disease, and the estimated risk of paediatric appendicitis by age 18 years was 2·5 per cent. Travel time to the treating hospital was not associated with complicated disease (adjusted odds ratio (OR) 1·00 (95 per cent c.i. 0·96 to 1·05) per 30‐min increase; P = 0·934). Level of education (P = 0·177) and family income (P = 0·120) were not independently associated with increased risk of complicated disease. Parental unemployment (adjusted OR 1·17, 95 per cent c.i. 1·05 to 1·32; P = 0·006) and having parents born outside Sweden (1 parent born in Sweden: adjusted OR 1·12, 1·01 to 1·25; both parents born outside Sweden: adjusted OR 1·32, 1·18 to 1·47; P < 0·001) were associated with an increased risk of complicated appendicitis.

Conclusion

Every sixth child diagnosed with appendicitis in Sweden has a more complicated course of disease. Geographical distance to the surgical facility was not a risk factor for complicated appendicitis.

Adherence to childhood cancer treatment: a prospective cohort study from Northern Vietnam

OBJECTIVES

Global incidence and attention to childhood cancer is increasing and treatment abandonment is a major cause of treatment failure in low- and middle-income countries. The purpose of this study was to gain an understanding of factors contributing to non-adherence to treatment.

DESIGN

A prospective cohort study with 2 year follow-up of incidence, family-reported motives and risk factors.

SETTING

The largest tertiary paediatric oncology centre in Northern Vietnam.

PARTICIPANTS

All children offered curative cancer treatment, from January 2008 to December 2009.

PRIMARY AND SECONDARY OUTCOME MEASURES

Family decision to start treatment was analysed with multivariable logistic regression, and family decision to continue treatment was analysed with a multivariable Cox model. This assessment of non-adherence is thereby methodologically consistent with the accepted definitions and recommended practices for evaluation of treatment abandonment.

RESULTS

Among 731 consecutively admitted patients, 677 were eligible for treatment and were followed for a maximum 2 years. Almost half the parents chose to decline curative care (45.5%), either before (35.2%) or during (10.3%) the course of treatment. Most parents reported perceived poor prognosis as the main reason for non-adherence, followed by financial constraints and traditional medicine preference. The odds of starting treatment increased throughout the study-period (OR 1.04 per month (1.01 to 1.07), p=0.002), and were independently associated with prognosis (OR 0.51 (0.41 to 0.64), p=<0.0001) and travel distance to hospital (OR 0.998 per km (0.996 to 0.999), p=0.004). The results also suggest that adherence to initiated treatment was significantly higher among boys than girls (HR 1.69 (1.05 to 2.73), p=0.03).

CONCLUSIONS

Non-adherence influenced the prognosis of childhood cancer, and was associated with cultural and local perceptions of cancer and the economic power of the affected families. Prevention of abandonment is a prerequisite for successful cancer care, and a crucial early step in quality improvements to care for all children with cancer.

A realized vision of access to safe, affordable surgical and anaesthesia care

Where is the funding?

Caesarean section performed by medical doctors and associate clinicians in Sierra Leone

BACKGROUND

Many countries lack sufficient medical doctors to provide safe and affordable surgical and emergency obstetric care. Task-sharing with associate clinicians (ACs) has been suggested to fill this gap. The aim of this study was to assess maternal and neonatal outcomes of caesarean sections performed by ACs and doctors.

METHODS

All nine hospitals in Sierra Leone where both ACs and doctors performed caesarean sections were included in this prospective observational multicentre non-inferiority study. Patients undergoing caesarean section were followed for 30 days. The primary outcome was maternal mortality, and secondary outcomes were perinatal events and maternal morbidity.

RESULTS

Between October 2016 and May 2017, 1282 patients were enrolled in the study. In total, 1161 patients (90·6 per cent) were followed up with a home visit at 30 days. Data for 1274 caesarean sections were analysed, 443 performed by ACs and 831 by doctors. Twin pregnancies were more frequently treated by ACs, whereas doctors performed a higher proportion of operations outside office hours. There was one maternal death in the AC group and 15 in the doctor group (crude odds ratio (OR) 0·12, 90 per cent confidence interval 0·01 to 0·67). There were fewer stillbirths in the AC group (OR 0·74, 0·56 to 0·98), but patients were readmitted twice as often (OR 2·17, 1·08 to 4·42).

CONCLUSION

Caesarean sections performed by ACs are not inferior to those undertaken by doctors. Task-sharing can be a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors.

Development of a Novel Global Surgery Course for Medical Schools

OBJECTIVE

We endeavored to create a comprehensive course in global surgery involving multinational exchange.

DESIGN

The course involved 2 weeks of didactics, 2 weeks of clinical rotations in a low-resource setting and 1 week for a capstone project. We evaluated our success through knowledge tests, surveys of the students, and surveys of our Zimbabwean hosts.

SETTING

The didactic portions were held in Sweden, and the clinical portion was primarily in Harare with hospitals affiliated with the University of Zimbabwe.

PARTICIPANTS

Final year medical students from Lund University in Sweden, Harvard Medical School in the USA and the University of Zimbabwe all participated in didactics in Sweden. The Swedish and American students then traveled to Zimbabwe for clinical work. The Zimbabwean students remained in Sweden for a clinical experience.

RESULTS

The course has been taught for 3 consecutive years and is an established part of the curriculum at Lund University, with regular participation from Harvard Medical School and the University of Zimbabwe. Participants report significant improvements in their physical exam skills and their appreciation of the needs of underserved populations, as well as confidence with global surgical concepts. Our Zimbabwean hosts thought the visitors integrated well into the clinical teams, added value to their own students' experience and believe that the exchange should continue despite the burden associated with hosting visiting students.

CONCLUSIONS

Here we detail the development of a course in global surgery for medical students that integrates didactic as well as clinical experiences in a low-resource setting. The course includes a true multilateral exchange with students from Sweden, the United States and Zimbabwe participating regularly. We hope that this course might serve as a model for other medical schools looking to establish courses in this burgeoning field.

Evaluating the collection, comparability and findings of six global surgery indicators

Background

In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates.

Methods

Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates.

Results

Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed.

Conclusion

Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.

Association of IgE-Mediated Allergy With Risk of Complicated Appendicitis in a Pediatric Population

IMPORTANCE

Childhood appendicitis is commonly complicated by gangrene and perforation, yet the causes of complicated appendicitis and how to avoid it remain unknown.

OBJECTIVE

To investigate whether children with IgE-mediated allergy have a lower risk of complicated appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included all consecutive patients younger than 15 years (hereinafter referred to as children) who underwent appendectomy for acute appendicitis at a tertiary pediatric surgery center in Sweden between January 1, 2007, through July 31, 2017. Children were stratified between those with and without IgE-mediated allergies.

MAIN OUTCOME AND MEASURES

Risk of complicated appendicitis with gangrene or perforation, with occurrence of IgE-mediated allergy as an independent variable and adjusted for age, sex, primary health care contacts, seasonal antigenic exposure, allergy medications, appendicolith, and duration of symptoms.

RESULTS

Of 605 included children (63.0% boys; median age, 10 years; interquartile range, 7-12 years), 102 (16.9%) had IgE-mediated allergy and 503 (83.1%) had no allergy. Complicated appendicitis occurred in 20 children with IgE-mediated allergy (19.6%) compared with 236 with no allergy (46.9%; adjusted odds ratio, 0.33; 95% CI, 0.18-0.59). No significant allergy effect modification by sex, seasonal antigenic exposure, or allergy medication was found. Children with IgE-mediated allergy had a shorter hospital stay (median, 2 days for both groups; interquartile range, 1-2 days vs 1-5 days; P = .004).

CONCLUSIONS AND RELEVANCE

In this study, children with IgE-mediated allergy had a lower risk of complicated appendicitis. The findings suggest that immunologic disposition modifies the clinical pattern of appendiceal disease. This theory introduces novel opportunities for understanding of the pathogenesis and clinical decision making for one of childhood's most common surgical emergencies.

The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap

Background

In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met.

Aim

To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone.

Methods

We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair.

Results

In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0–15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0–15 years of age. The estimated unmet need for inguinal hernia repair was 88%.

Conclusions

The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.

Long-Term Outcome of Sacrococcygeal Teratoma: A Controlled Cohort Study of Urinary Tract and Bowel Dysfunction and Predictors of Poor Outcome

OBJECTIVE

To evaluate urinary tract and bowel function in children with sacrococcygeal teratoma, compare the findings with healthy children, and assess predictors of poor outcome.

STUDY DESIGN

This was a controlled cohort study of all patients operated for sacrococcygeal teratoma at a tertiary pediatric surgery center, 2000-2013. Urinary and bowel function were compared with healthy control patients matched for age and sex. Perioperative and histopathologic risk factors were analyzed.

RESULTS

In total, 17 patients with sacrococcygeal teratoma and 85 healthy control patients were included in the study. Patients with sacrococcygeal teratoma more often were reported to have uncontrolled voiding (12% vs 0%, P < .01), difficulty in bladder emptying (24% vs 0%, P < .001), and pyelonephritis (18% vs 1%, P < .05). Constipation was more common in patients with sacrococcygeal teratoma (47 % vs 14%, P < .05), but the overall bowel function score was equal in the 2 groups. Children with large tumors and immature histology were more likely to have a dysfunctional outcome (P < .05).

CONCLUSIONS

Uncontrolled voiding, difficulty in bladder emptying, pyelonephritis, and constipation were more common in patients with sacrococcygeal teratoma than in healthy children. Dysfunctional outcome was more prevalent in children with large and immature teratomas.

Cryptorchidism in Sweden: A Nationwide Study of Prevalence, Operative Management, and Complications

OBJECTIVES

To review the cumulative prevalence, operative management, and complications of treatment for cryptorchidism in Sweden.

STUDY DESIGN

A nationwide observational study from longitudinal register data of all Swedish-born boys 0-18 years of age, diagnosed with cryptorchidism from 2001 to 2014. Primary outcomes were occurrence and age at primary surgery. Secondary outcomes included type of procedure and surgical site infection.

RESULTS

Of 20 375 boys diagnosed with cryptorchidism in 2001-2014, 12 766 were surgically treated. The cumulative childhood prevalence was 1.8% (95% CI, 1.5-2.0), with a higher prevalence in boys born prematurely, small for gestational age, or with low birth weight. The median age at treatment decreased from 6.2 years in 2001 to 3.4 years in 2014 (P < .001). Still, 94.1% (95% CI, 92.7-95.6) had surgery after the recommended 1 year of age in 2014. Variations in age at surgery between Swedish counties were great (range, 2.9-5.9 years of age). There were no deaths within 30 days after surgery and the frequency of surgical site infection was low (1.4%; 95% CI, 1.1-1.6).

CONCLUSIONS

The cumulative childhood prevalence of cryptorchidism was high, and complications were rare. Few boys underwent surgery in a timely manner according to clinical guidelines, and standards of care varied considerably across the country. Further research and collective actions are needed to improve the detection and management of congenital cryptorchidism.

Population-based incidence rate of inpatient and outpatient surgical procedures in a high-income country

BACKGROUND

The WHO and the World Bank ask countries to report the national volume of surgery. This report describes these data for Sweden, a high-income country.

METHODS

In an 8-year population-based observational cohort study, all inpatient and outpatient care in the public and private sectors was detected in the Swedish National Patient Register and screened for the occurrence of surgery. The entire Swedish population was eligible for inclusion. All patients attending healthcare for any disease were included. Incidence rates of surgery and likelihood of surgery were calculated, with trends over time, and correlation with sex, age and disease category.

RESULTS

Almost one in three hospitalizations involved a surgical procedure (30·6 per cent). The incidence rate of surgery exceeded 17 480 operations per 100 000 person-years, and at least 58·5 per cent of all surgery was performed in an outpatient setting (range 58·5 to 71·6 per cent). Incidence rates of surgery increased every year by 5·2 (95 per cent c.i. 4·2 to 6·1) per cent (P < 0·001), predominantly owing to more outpatient surgery. Women had a 9·8 (95 per cent c.i. 5·6 to 14·0) per cent higher adjusted incidence rate of surgery than men (P < 0·001), mainly explained by more surgery during their fertile years. Incidence rates peaked in the elderly for both women and men, and varied between disease categories.

CONCLUSION

Population requirements for surgery are greater than previously reported, and more than half of all surgery is performed in outpatient settings. Distributions of age, sex and disease influence estimates of population surgical demand, and should be accounted for in future global and national projections of surgical public health needs.

The Surgical Workforce and Surgical Provider Productivity in Sierra Leone: A Countrywide Inventory

Background

Limited data exist on surgical providers and their scope of practice in low-income countries (LICs). The aim of this study was to assess the distribution and productivity of all surgical providers in an LIC, and to evaluate correlations between the surgical workforce availability, productivity, rates, and volume of surgery at the district and hospital levels.

Methods

Data on surgeries and surgical providers from 56 (93.3 %) out of 60 healthcare facilities providing surgery in Sierra Leone in 2012 were retrieved between January and May 2013 from operation theater logbooks and through interviews with key informants.

Results

The Sierra Leonean surgical workforce consisted of 164 full-time positions, equal to 2.7 surgical providers/100,000 inhabitants. Non-specialists performed 52.8 % of all surgeries. In rural areas, the densities of specialists and physicians were 26.8 and 6.3 times lower, respectively, compared with urban areas. The average individual productivity was 2.8 surgeries per week, and varied considerably between the cadres of surgical providers and locations. When excluding four centers that only performed ophthalmic surgery, there was a positive correlation between a facility’s volume of surgery and the productivity of its surgical providers (r_s = 0.642, p < 0.001).

Conclusions

Less than half of all of the surgery in Sierra Leone is performed by specialists. Surgical providers were significantly more productive in healthcare facilities with higher volumes of surgery. If all surgical providers were as productive as specialists in the private non-profit sector (5.1 procedures/week), the national volume of surgery would increase by 85 %.

Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea, Uganda, and Sierra Leone

BACKGROUND

Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs.

METHODS AND FINDINGS

We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable.

CONCLUSIONS

National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.

Global Surgery 2030: a roadmap for high income country actors

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

Sacrococcygeal teratoma: A population-based study of incidence and prenatal prognostic factors

BACKGROUND

Sacrococcygeal teratoma (SCT) is a rare congenital tumor associated with high rates of perinatal mortality and morbidity. This study evaluated the incidence, prenatal detection rate, and early predictors of a complicated outcome following diagnosis of SCT.

METHODS

We retrospectively identified all fetuses and newborns diagnosed with SCT in southern Sweden from 2000 to 2013. Prenatal sonograms, charts, and pathology reports were reviewed and analyzed. Each case of SCT was defined as complicated or uncomplicated based on the postnatal outcome. All cases with a fatal outcome or that required cardiac resuscitation during birth or surgery were classified as complicated.

RESULTS

The overall incidence of SCT was 1:13,982 (19 children in a cohort of 265,658 live births). A prenatal diagnosis was made in 74% of cases, there were no stillbirths or intrauterine deaths, and the overall mortality rate was 11%. Four cases of SCT (21%) were classified as complicated, and these cases had a significantly larger tumor size at gestational week 20 (P=0.048), had a significantly higher tumor growth rate (P=0.003), and were more often associated with polyhydramnios (P=0.01), and mainly solid/mixed morphology (P=0.001).

CONCLUSIONS

The incidence of SCT in southern Sweden was higher than those reported in most previous studies; however, the associated mortality rate was relatively low. Fetuses with large tumors, rapidly growing tumors, and polyhydramnios were more likely to experience a complicated outcome during the postnatal period.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.